Mental health waiting times risk more child deaths, coroner warns

Madeleine Savory was on a ward at Ipswich Hospital while waiting for a mental health unit bed to become available

A coroner has warned that more people are at risk of dying due to waiting times for urgent mental health beds.

Madeleine Savory, 15, died in Suffolk in February 2022 after attempting to end their life at Ipswich Hospital.

Coroner Darren Stewart, who conducted the inquest into their death, said he would write a prevention of future deaths report citing his concerns about delays.

The Department for Health has been contacted for comment.

At the inquest, Mr Stewart concluded that failures at Ipswich Hospital, Northgate High School and around the availability of mental health beds contributed to the death of Madeleine, who used they/them pronouns.

He said changes made by the hospital, run by East Suffolk and North Essex Foundation Trust, along with Norfolk and Suffolk NHS Foundation Trust and the school since Madeleine's death had all addressed his concerns.

Madeleine had self-harmed on 3 February 2022 and was admitted to hospital and placed on a list for a mental health unit bed on 7 February.

While waiting for a bed, they made a suicide attempt on 19 February and died a week later.

• Multiple agency failures contributed to teen death

• Teen died after attempt on own life in hospital

• Staff did not check teen's self-harm past - inquest

Mr Stewart said many of the issues impacting the effectiveness of the local collaborative that allocated urgent beds were "controlled at a national level in terms of resourcing, coordination and availability of staff".

He said he would write a prevention of future deaths report to the Health Secretary about the issue.

Mr Stewart said while measures had been taken to mitigate and reduce waiting times "it remains that these mental health patients are the most vulnerable within our community."

He added: "Children and young people face waiting lists and delays in accessing appropriate care."

He said better coordination at a national level could avoid future deaths and "perhaps may have avoided in Madeleine's case their very sad death".

In a statement following the inquest, Madeleine's family said they were "heartbroken and devastated" and hoped lessons would be learnt to "avoid another child and family having to go through the indescribable pain and torment we have endured."

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